Citation Nr: 1805388 Decision Date: 01/26/18 Archive Date: 02/07/18 DOCKET NO. 11-05 377 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for bilateral pes planus. 2. Entitlement to an increased initial rating, in excess of 10 percent, for pseudofolliculitis barbae ("PFB"). 3. Entitlement to an initial compensable rating for bilateral tinea pedis. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Timbers, Associate Counsel INTRODUCTION The Veteran served as a member of the United States Navy, with active duty service from October 2007 through September 2009. This appeal comes to the Board of Veterans' Appeals ("Board") from a March 2010 rating decision by the Department of Veterans Affairs ("VA") Regional Office ("RO") in Waco, Texas (hereinafter Agency of Original Jurisdiction ("AOJ")). The Veteran testified at a September 2016 Board videoconference hearing, held before the undersigned Veterans Law Judge. A transcript of this hearing has been reviewed and associated with the Veteran's claims file. In May 2017, the Board remanded the Veteran's appeal to the AOJ for further development. Specifically, the Board requested that the AOJ obtain the Veteran's updated VA treatment records and provide the Veteran with a VA examination and medical opinion for his bilateral pes planus disability. A review of the claims file indicates that the requested development has been completed and that the Veteran's appeal has been properly returned to the Board. See Stegall v. West, 11 Vet. App. 268 (1998). This appeal was processed using Virtual VA and the Veterans Benefits Management System ("VBMS"). Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The issue of entitlement to an increased evaluation for the service connected pseudofolliculitis barbae disability is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran entered active duty service in October 2007 with a preexisting bilateral pes planus disability. The evidence does not show that the Veteran experienced a permanent increase in the severity or symptoms of bilateral pes planus disability during his active duty service beyond its natural progression. 2. The evidence of record does not show that the Veteran's bilateral tinea pedis disability covered at least five percent of his total body at any point during the period on appeal. CONCLUSIONS OF LAW 1. The Veteran's pre-existing bilateral pes planus disability was not aggravated by the Veteran's active duty service. 38 U.S.C. §§ 1110, 1111, 1153, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306 (2017). 2. The criteria for an initial compensable evaluation, for the bilateral tinea pedis disability, have not been met or approximated at any time relevant to the period on appeal. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.20, 4.27, 4.118, Diagnostic Codes 7806, 7813 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act ("VCAA") must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his or her claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2017). In regards to the Veteran's claims for entitlement to service connection, the Board notes that the VA notified the Veteran of the information and evidence needed to substantiate and complete his claim, including what part of that evidence he was to provide and what part VA would attempt to obtain on his behalf, in correspondence dated October 2009 and August 2013. See 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). These letters informed the Veteran to submit medical evidence relating the claimed disabilities to active service and noted other types of evidence the Veteran could submit in support of his claim. The Veteran also was informed of when and where to send the evidence. After consideration of the contents of this letter, the Board finds that VA has satisfied substantially the requirement that the Veteran be advised to submit any additional information in support of his claims for entitlement to service connection. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Additional notice of the five elements of a service-connection claim was provided in the October 2009 VCAA notice, as is required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). As to the Veteran's claim for an increased evaluation of his service connected bilateral tinea pedis disability, the Board notes that this claim is considered a "downstream" element of the AOJ's grant of service connection. For such downstream issues, notice under 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159 is not required in cases where such notice was afforded for the originating issue of service connection. See VAOPGCPREC 8-2003 (Dec. 22, 2003). Courts have held that once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), see also Dunlap v. Nicholson, 21 Vet. App. 112 (2007). In correspondence dated October 2009, VA notified the Veteran of the information and evidence needed to substantiate and complete his claim for entitlement to service connection for a bilateral tinea pedis disability, including what part of the evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 6 Vet. App. 183, 187 (2002). However, the Board notes that the November 2010 Statement of the Case explained the criteria necessary in order for the Veteran to substantiate the claim for an increased evaluation for his bilateral tinea pedis disability. The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the Board. It appears that all known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. This includes the Veteran's updated treatment records from the Dallas VA Medical Center ("VAMC") which were requested as part of the Board's May 2017 remand. See Stegall, 11 Vet. App. 268 at 271. The Veteran has been provided with multiple VA examinations which addressed the Veteran's reported symptoms, frequency, and severity and the interference these symptoms cause in his ability to complete basic daily tasks. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Most recently, the Veteran was provided with an examination and medical opinion in July 2017, as requested by the Board's prior remand. See Stegall, 11 Vet. App. 268 at 271. During this July 2017 examination, the pertinent medical history was noted by the examiner and the examiner's findings were set forth in detail, allowing for informed appellate review under applicable VA laws and regulations. Thus, the Board finds the examination of record are adequate for rating purposes and an additional examination is not necessary regarding the claims adjudicated in this decision. See also 38 C.F.R. §§ 3.326, 3.327, 4.2. The Veteran was afforded the opportunity to appear and testify before the undersigned Veterans Law Judge ("VLJ") via video conference hearing in September 2016. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge ("VLJ") who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ noted the basis of the prior determination and noted the element of the claims that was lacking to substantiate the claims for benefits. The VLJ specifically noted the issues as including the issues listed on the title page of this decision. The Veteran was assisted at the hearing by an accredited representative from Disabled American Veterans. The representative and the VLJ then asked questions to ascertain whether the Veteran had submitted evidence in support of these claims. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claims. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that any error in notice provided during the Veteran's hearing constitutes harmless error. Based upon the above, the Board finds that VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA. Moreover, the neither the Veteran nor his representative have advanced any procedural arguments in relation to VA's duties to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015) (holding that "absent extraordinary circumstances . . . we think it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran . . ."). Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. Lastly, the Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). General Rules and Regulations of Service Connection: The Veteran currently seeks entitlement to service connection for a bilateral pes planus disability. Although this disability preexisted his military service, the Veteran contends the physical requirements of active duty aggravated his condition beyond its normal progression. See e.g. September 2016 Hearing Testimony. When an issue is raised as to whether the disorder claimed by the Veteran preexisted service, the governing law provides that every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable (obvious or manifest) evidence demonstrates that (1) an injury or disease existed before acceptance and enrollment into service (2) and was not aggravated by such service. See 38 U.S.C. §§ 1111, 1132, 1137; 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). See also VAOPGCPREC 3-2003 (July 16, 2003). This statutory provision is referred to as the "presumption of soundness." Horn v. Shinseki, 25 Vet. App. 231, 234 (2012). However, if a preexisting disability is noted upon entry into service, the Veteran cannot bring a claim for service connection for that particular disability, but the Veteran may bring a claim for service-connected aggravation of that disability. In that case, § 1153 applies and the burden falls on the Veteran to establish aggravation. Wagner, 370 F.3d at 1096; Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). A preexisting injury or disease will be considered to have been aggravated during service when there is an increase in disability during service, unless there is a specific finding (clear and unmistakable evidence) that the increase in disability is due to the natural progression of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service. 38 C.F.R. § 3.306(b). The presumption of aggravation applies only when the Veteran shows the pre-service disability increased in severity during service. Beverly v. Brown, 9 Vet. App. 402, 405 (1996). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306; Falzone v. Brown, 8 Vet. App. 398, 402 (1995). Temporary or intermittent flare-ups of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition itself, as contrasted with mere symptoms, has worsened. See Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); see also Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Accordingly, "a lasting worsening of the condition" - that is, a worsening that existed not only at the time of separation but one that still exists currently is required. See Routen v. Brown, 10 Vet. App. 183, 189 n. 2 (1997); see also Verdon v. Brown, 8 Vet. App. 529, 538 (1996). The presumption of aggravation only requires evidence of an actual worsening of a preexisting condition during service; it does not require direct evidence of nexus, that is, that the worsening was actually caused by service. Smith v. Shinseki, 24 Vet. App. 40, 47-48 (2010) (emphasis added). Therefore, a veteran must initially establish only that a preexisting condition worsened during service, and at that point the veteran has the benefit of the presumption of aggravation. Moreover, the presumption of aggravation applies where there was a worsening of the disability in service, regardless of whether the degree of worsening was enough to warrant compensation per the Schedule for Rating Disabilities ("Rating Schedule). Browder v. Derwinski, 1 Vet. App. 204, 206-207 (1991). If a permanent increase is shown, the presumption of aggravation may be rebutted only by clear and unmistakable evidence that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a), (b). Independent medical evidence is needed to support a finding that the preexisting disorder increased in severity in service beyond its natural progression. See Paulson v. Brown, 7 Vet. App. 466, 470-471 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1994). In the instant appeal, the Veteran's bilateral pes planus was noted during his October 2007 enlistment physical examination. This entrance examination reported the Veteran had "severe" and "asymptomatic" bilateral pes planus. Therefore, the condition was not considered disabling at that time. A disorder can be asymptomatic, but still considered as "noted" on entrance. Verdon v. Brown, 8 Vet. App. 529, 534-535 (1996). Additionally, in the self-reported history portion of this entrance examination, the Veteran denied any history of foot trouble. Therefore, based on this evidence, a bilateral pes planus condition of the feet was clearly noted at entrance. Since this disability was noted at the time of the Veteran's entrance into service, the Veteran is not entitled to the presumption of soundness for this particular disability when entering service. See 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). As the Veteran's bilateral pes planus was documented at his entrance to active duty service, it is the Veteran's burden to show that a chronic (i.e. permanent) worsening of his preexisting disability during service. Horn, 25 Vet App. at 238. In this regard, the Board finds no evidence that the Veteran ever sought treatment for, or complained of, any bilateral foot pain or related symptoms during his active duty service. The Board finds the total absence of treatment for his bilateral pes planus to be significant, as the Veteran was examined on a regular basis for periodic health assessments ("PHA"). At no time during any of these encounters did the Veteran ever report or indicate he was experiencing symptoms of bilateral pes planus. Additionally, objective observations during his active duty service do not suggest that the Veteran experienced any difficulty with ambulation or bilateral foot pain. At no time did any examining physician report that the Veteran walked with difficulty or that he experienced pain with manipulations of his feet. To the contrary, these clinical observations of the Veteran noted that he walked with a normal gait and stance. See e.g. PHA Dated October 8, 2008. These service medical records additionally show that the Veteran was routinely cleared for training exercises, and that no limitation or modification was provided based upon his bilateral pes planus. The Board further observes that the Veteran made no report or mention of any worsening of his bilateral pes planus during his August 2009 separation examination. The Veteran did, however, report a worsening of his bilateral tinea pedis during service, but made no mention or report of any foot pain. Thus, the Board finds that the Veteran's service medical records do not provide any suggestion that the symptoms of his bilateral pes planus worsened during his active duty service. A review of the Veteran's post-service medical records does not support a finding that the bilateral pes planus disability was permanently worsened. Following his discharge from military service, the Veteran underwent a general medical examination in September 2010. During this evaluation, the examiner reported the Veteran has "obvious" bilateral pes planus with non-weight bearing, and that this disability increased with weight-bearing. The examiner reported no other deformities of the feet, and observed that the Achilles tendon was straight and non-tender. Notably, the examiner reported the Veteran experienced only "minimal" tenderness to palpation on the mid arches of both feet. The Board finds this September 2010 examination to be significant. Specifically, despite the Veteran's reports of chronic bilateral foot pain, the examiner reported the Veteran experienced only "minimal" tenderness to palpation of his feet. Comparing this finding to the Veteran's October 2007 entrance examination, the Board acknowledges that the Veteran's bilateral pes planus had increased from "asymptomatic" to findings of "minimal" tenderness. However, this finding does not support the Veteran's contention that his bilateral pes planus disability underwent a permanent worsening during his active duty service. See Verdon, 8 Vet. App. at 538. Moreover, the Board does not find this report of "minimal" tenderness represents a permanent increase in severity of the bilateral pes planus disability. A review of the Veteran's longitudinal medical records indicates he did not seek any further treatment for his bilateral pes planus disability for several years. When the Veteran did seek medical treatment for complaints of foot pain, the Board finds it significant that the Veteran reported an increase in pain due to the nature of his work (i.e. that he was hired by UPS and was required to spend long hours on his feet in work boots). See e.g. Dallas VAMC Records, dated August 2015. Therefore, based upon the Veteran's own reports, these increased foot symptoms were due to a change in his occupation and were not a continuation of his in-service symptoms. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (holding that lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). Overall, an in light of the evidence summarized above, the Board finds the Veteran has not met his burden to show a worsening of his bilateral pes planus disability during his active duty service. Based upon a review of the Veteran's service medical records, the Board finds no evidence that the Veteran ever sought or received treatment for symptoms of his pes planus disability. This lack of treatment, coupled with the absence of any notation of the condition on the August 2009 separation physical examination, suggests that there was no permanent worsening of the Veteran's bilateral pes planus disability during service. In reaching this conclusion, that there was no aggravation, the Board has considered the Veteran's lay reports of symptoms during service. For example, during his September 2010 medical examination, the Veteran reported that he experienced pain in his bilateral feet during his active duty service. The Veteran also stated that he was treated for these symptoms during service and that he was given shoe inserts, which did not prove to be helpful. While the Board has considered these statements, the Board does not find them sufficient to satisfy the burden of establishing aggravation. While the Veteran may have experienced bilateral foot pain during service, there is no evidence to suggest that these symptoms represented a permanent worsening of his disability. Rather, the Board finds that these reports of symptoms represent temporary or intermittent flare-ups of his disability which abated over time. Without any objective findings showing a permanent increase in the disability, the Board finds that these reports of symptoms do not establish that the disability was aggravated by the Veteran's active duty service. See Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002) (which holds that evidence of a temporary flare up, without more, does not satisfy the level of proof required of a non-combat Veteran to establish an increase in disability). As for the medical opinion evidence of record, the Board finds the July 2017 examination and opinion to be probative and entitled to significant weight. Following a physical examination of the Veteran and a review of his medical records, the examiner concluded that there was no evidence to support a finding that the Veteran's bilateral pes planus was permanently worsened by his active duty service. In support of this conclusion, the examiner cited to the October 2007 entrance examination which found the Veteran's bilateral pes planus to be "asymptomatic." Continuing, the examiner noted that the service medical records documented no evidence of complaints, or other findings, which would suggest his disability became symptomatic during his active duty service. The examiner highlighted the absence of any reports of symptoms on the August 2009 separation examination as significant because the Veteran reported an increase in severity of a foot rash, but made no mention of any increased symptoms of his bilateral pes planus. The examiner also found no evidence to support a finding that the Veteran's gait was altered due to his foot rash (and/or blisters), which would have contributed to a worsening of the bilateral pes planus disability. After reviewing the Veteran's service medical records, the examiner observed that his gait was reported as normal throughout his service. Thus, without documentation of an altered gait, the examiner concluded that there was no evidence to support a finding that the Veteran's foot rash caused him to alter his gait and thereby aggravated his bilateral pes planus disability. The Board finds the opinion and conclusions of the July 2017 examiner to be thorough, as it considered both the medical evidence and the Veteran's lay reports of symptoms, and supported by a clear rationale. The examiner provided specific citations to the Veteran's longitudinal medical records when making his conclusions, thereby allowing for informed appellate review under applicable VA laws and regulations. As such, the Board finds this July 2017 medical opinion to be probative and entitled to significant weight. In conclusion, the Board finds that the weight of the competent and credible evidence is against a finding that the Veteran's bilateral pes planus disability was aggravated by his active duty service. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Governing Laws and Regulations for Increased Ratings Claims: Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities ("Rating Schedule"), found in 38 C.F.R. § 4.1 (2017). The rating schedule is primarily a guide in the evaluation of disabilities resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. Separate diagnostic codes identify the various disabilities and each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.10. As such, each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where, as here, the question for consideration is the propriety of the initial evaluation assigned, the relevant time period for consideration begins on the date that the claim for service connection was filed. Moore v. Nicholoson, 21 Vet. App. 211, 216-17 (2007). In the instant appeal, that date is September 12, 2009. Moreover, the Board acknowledges that a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and coordination of rating with impairment of function. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. That being the relevant generalized law to the increased rating claim, the Board observes the Veteran's bilateral tinea pedis has been rated under Diagnostic Code 7813, for Dermatophytosis. 38 C.F.R. § 4.118. Diagnostic Code 7813 directs that a skin disability shall be rated be rated as disfigurement or scars of the head, face, or neck under Diagnostic Code 7800; as scars under Diagnostic Codes 7801 through 7805; or as dermatitis under Diagnostic Code 7806, depending on the predominant disability. The Veteran's bilateral tinea pedis disability is characterized by symptoms including rashes, whitish skin discolorations, dry and cracked skin, and itching. See Examinations dated July 2013 and July 2017. As such, the Board finds that the Veteran's disability is most appropriately rated under Diagnostic Code 7806, for dermatitis or eczema. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (choice of diagnostic code should be upheld if it is supported by explanation and evidence). Under Diagnostic Code 7806, a noncompensable rating is assigned were less than five percent of the entire body is affected, or less than five percent of the exposed areas (such as the hands, face, and neck) are affected, and the disability has required no more than topical therapy during the past 12 month period. A 10 percent rating is warranted if at least five percent, but less than 20 percent, of the entire body, or at least five percent, but less than 20 percent, of exposed areas are affected, or; if intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than six weeks during the past 12 month period. A 30 percent rating is warranted if 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; if systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past 12 month period. A 60 percent rating is warranted if more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or; if constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12 month period. See 38 C.F.R. § 4.118, Diagnostic Code 7806 (2017). The Board notes that in October 2008, regulations pertaining to the evaluation of the skin were amended effective October 23, 2008. It is further observed that the regulatory changes apply to applications received by VA on or after October 23, 2008, or where a claimant requests readjudication under the new criteria.. See 73 Fed. Reg. 54, 708 (Sept. 23, 2008) (codified at 38 C.F.R. § 4.118, Diagnostic Codes 7800-05 (2013)). As applied to the Veteran's instant appeal, he was initially granted entitlement to service connection, and assigned a non-compensable evaluation, effective September 12, 2009. Therefore, reference to the regulations in effect prior to September 23, 2008 is not necessary. The Board has reviewed the Veteran's longitudinal medical records, and finds that the preponderance of the evidence does not warrant the assignment of a compensable evaluation for the bilateral tinea pedis disability, at any time during the period on appeal. For example, during an examination in July 2013, the Veteran's bilateral tinea pedis was observed to cover no more than five percent of the feet. The examiner reported the Veteran's bilateral tinea pedis was present on the bilateral feet at the fourth and fifth web spaces only, and was characterized by maceration and whitish discoloration. The Board is aware that the July 2013 examiner concluded that the between five and 20 percent of the Veteran's body was affected by a skin disability. However, based upon the examiner's description of the Veteran's tine pedis and his additional service-connected disability of pseudofolliculitis barbae, the Board concludes that the examiner found the pseudofolliculitis barbae disability to affect between five and 20 percent of the Veteran's total body. See Examiner's conclusion in same medical opinion that the pseudofolliculitis barbae disability was singularly observed to cover five to 20 percent of the Veteran's skin. A review of the Veteran's subsequent medical records does not suggest that his bilateral tinea pedis worsened such that it covered at least five percent of his entire body. For example, during an examination in July 2017, the Veteran's bilateral tinea pedis was observed to affect less than five percent of the Veteran's total body area. Additionally, the examiner reported that while the Veteran had been prescribed medications for his disability, this medication was topical therapy only, as opposed to intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs. The Board is aware that the Veteran, through his representative, has argued that an increased rating is warranted based upon the Veteran's prescription medication for his bilateral tinea pedis. See e.g. December 2017 Appellant's Brief. Specifically, the representative argued that the July 2017 examiner did not review the Veteran's medical records and therefore did not consider his prescription medication for a topical cream. However, the Board finds this argument is misplaced, as the examiner both reviewed the Veteran's medical records and specifically cited to his perception medication for his bilateral tinea pedis. Although the Veteran has been prescribed medication for his bilateral tinea pedis, this medication is topical ointment only. After reviewing the Veteran's medical records, the July 2017 examiner made note of this medication, and that the ointment is used continuously, but reported that this prescription did not warrant a compensable evaluation because it was not an intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs. Furthermore, based upon the Board's own review of the Veteran's longitudinal medical records, the Board finds that there is no evidence to suggest that the Veteran was ever prescribed any corticosteroids, or other such immunosuppressive drugs, for his bilateral tinea pedis disability. See Dallas VAMC Records. Rather, the Veteran's active prescription medications list indicates he has been prescribed Mupirocin, which is a topical ointment and not a systemic medication. Therefore, the Board finds no evidence which would warrant the assignment of a compensable evaluation for the Veteran's bilateral tinea pedis. With regard to the additional diagnostic codes concerning disabilities affecting the skin, the Veteran does not contend, nor does the evidence reflect, that he would warrant a separate or higher rating for American leishmaniasis (Diagnostic Code 7807); Old World leishmaniasis (Diagnostic Code 7808); discoid lupus erythematosus or subacture cutaneous lupus erythematosus (Diagnostic Code 7809); tuberculosis luposa (lupus vulgaris), active or inactive (Diagnostic Code 7811); dermatophytosis (ringworm: of body, tinea corporis; of head, tinea capitis; of feet, tinea pedis; of beard area, tinea barbae; of nails, tinea unguium; of inguinal area (jock itch), tinea cruris) (Diagnostic Code 7813); bullous disorders (including pemphigus vulgaris, pemphigus foliaceous, bullous pemphigoid, dermatitis herpetiformis, epidermolysis bullosa acquisita, benign chronic familial pemphigus (Hailey-Hailey), and porphyria cutanea tarda) (Diagnostic Code 7815); psoriasis (Diagnostic Code 7816); exfoliative dermatitis (erythroderma) (Diagnostic Code 7817); malignant skin neoplasms (other than malignant melanoma) (Diagnostic Code 7818); benign skin neoplasms (Diagnostic Code 7819); cutaneous manifestations of collagen-vascular diseases not listed elsewhere (including scleroderma, calcinosis cutis, and dermatomyositis) (Diagnostic Code 7821); papulosquamous disorders not listed elsewhere (including lichen planus, large or small plaque parapsoriasis, pityriasis lichenoides et varioliformis acuta (PLEVA), lymphomatoid papulosus, and pityriasis rubra pilaris (PRP)) (Diagnostic Code 7822); Vitiligo (Diagnostic Code 7823); diseases of keratinization (including icthyoses, Darier's disease, and palmoplantar keratoderma) (Diagnostic Code 7824); urticaria (Diagnostic Code 7825); primary cutaneous vasculitis (Diagnostic Code 7826); erythema multiforme or toxic epidermal necrolysis (Diagnostic Code 7827); acne (Diagnostic Code 7828); chloracne (Diagnostic Code 7829); scarring alopecia (Diagnostic Code 7830); alopecia areata (Diagnostic Code 7831); hyperhidrosis (Diagnostic Code 7832); or malignant melanoma (Diagnostic Code 7833). See 38 C.F.R. § 4.118. In conclusion, the probative medical evidence establishes that the Veteran does not meet the criteria for an initial compensable evaluation of his service connected bilateral tinea pedis at any point during the period on appeal. See Fenderson, 12 Vet. App. at 126. The Board has additionally considered whether the Veteran's skin disability is entitled to an extraschedular rating. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2017); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). The determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b)(1) is a three-step inquiry. Thun v. Peake, 22 Vet. App. 111, 115-116 (2008). If the RO or Board determines that (1) the schedular evaluation does not contemplate the claimant's level of disability and symptomatology, and (2) the disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization, then (3) the case must be referred to an authorized official to determine whether, to accord justice, an extra- schedular rating is warranted. Id. See also 38 C.F.R. § 3.321(b)(1). Neither the RO nor the Board is permitted to assign an extraschedular rating in the first instance; rather the matter must initially be referred to those officials who possess the delegated authority to assign such a rating. See Anderson v. Shinseki, 22 Vet. App. 423, 427-8 (2009); Floyd v. Brown, 9 Vet. App. 88, 96-97 (1996). Having reviewed this case thoroughly, and with due application of the substantive standards for the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1), the Board finds that no higher rating is warranted on an extraschedular basis. The Board does not find that the longitudinal evidence of record shows such an exceptional disability picture that the available schedular evaluation for the service-connected skin disability is inadequate or impractical for evaluating a disability of the severity experienced by the Veteran. Rather, a comparison between the level of severity and symptomatology of the Veteran's assigned evaluation with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Specifically, the Veteran reports his skin disability is characterized by itching, rashes, discoloration, discomfort, and functional effects such as an inability to difficulty with prolonged ambulation. At no point during the pendency of his appeal has the Veteran reported or alleged any debilitating episodes of his bilateral tinea pedis. See e.g. July 2017 Examination. Under his presently assigned Diagnostic Code 7806, none of the above symptoms are referenced or listed. Rather, the Diagnostic Code assigns ratings based upon the frequency and severity of the Veteran's symptoms. However, the lack of specific reference to the Veteran's reported symptoms does not in and of itself warrant a referral for an extraschedular evaluation. Moreover, as discussed above, the Board considered the Veteran's reported symptomatology under multiple Diagnostic Codes. As 38 C.F.R. § 4.118 specifies the Board is to consider numerous possible codes, which address a myriad of symptoms, the Board finds there is no symptom alleged by the Veteran which was not fully considered in the Board's analysis. This approach is in keeping with the fact that, as explained above, the rating criteria are not meant to compensate for specific signs or symptoms, but rather for the resulting disability in terms of the impact on one's ability to function in daily life and employment. See 38 C.F.R. § 4.10. Again, the rating criteria must generally be assumed to be adequate in this regard absent a specific showing to the contrary. See 38 C.F.R. § 4.1. It also bears re-emphasizing that the schedular ratings are averages and need not completely account for each individual veteran's circumstances in order to be adequate for evaluation purposes. See Thun, 22 Vet. App. at 114; see also 38 C.F.R. § 4.21 (providing that in view of the number of atypical instances, it is not expected that all cases will show all the findings specified in the criteria, but that coordination of rating with impairment of function will be expected in all instances). Thus, the fact that the disability may impose external challenges or circumstances unique to the claimant and not specifically mentioned in the criteria does not alone show that application of the regular schedular standards is impractical. Cf. VAOPGCPREC 6-96 (August 16, 1996) (holding that the fact that circumstances specific to a claimant may cause the effects of a service-connected disability to be more profound in that claimant's case does in itself provide a basis for extraschedular referral). In sum, for the reasons explained above, there are no disabling effects of the Veteran's skin disorder not accounted for under the schedular criteria such as to render their application impractical, even if a given sign, symptom, or example of functional impairment or external challenge is not specifically mentioned in the rating criteria. See Thun, 22 Vet. App. at 115; 38 C.F.R. § 3.321(b). Accordingly, the available schedular evaluations are adequate to rate this disability, and the first step of the inquiry is not satisfied. See id. In the absence of this threshold finding, the second step of the inquiry, namely whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization, is moot. See Thun at 118-19. Therefore, the Board will not refer the evaluation of the Veteran's skin disorder for extraschedular consideration. See id.; 38 C.F.R. § 3.321(b). ORDER Service connection for a bilateral pes planus disability is denied. Entitlement to an initial compensable evaluation for the bilateral tinea pedis disability is denied. REMAND While the Board regrets further delay, the Veteran's claim must be remanded as additional development is required. During the pendency of the instant appeal, the Veteran, through his representative, has alleged a worsening of his pseudofolliculitis barbae disability. See e.g. December 2017 Appellant's Brief. Additionally, the Board finds that the medical records obtained since the date of the Board's prior May 2017 remand substantiate the Veteran's claim, as the medical records show he has sought treatment for a worsening of this disability. For example, in February 2017, the Veteran sought emergency treatment for symptoms of "bumps" on his head which have progressively gotten worse. See Dallas VAMC Records. The Veteran has additionally sought treatment for symptoms of pseudofolliculitis barbae in September 2016, reporting his condition worsens after shaving. When a Veteran asserts that a disability has worsened since his last VA examination, and the last examination is too remote to constitute a contemporaneous examination, a new examination is required. See 38 U.S.C. § 5103A(d); 38C.F.R. § 3.159(c)(4); See also Snuffer v. Gober, 10 Vet. App. 400 (1997); Green v. Derwinski, 1 Vet. App. 121 (1991). Therefore, on remand, the Veteran should be provided with an updated VA dermatologic examination to assess the current severity of his pseudofolliculitis barbae disability. Finally, as this claim is being remanded, the AOJ should obtain the Veteran's updated VA treatment records and associated them with the claims file. VA's duty to assist includes obtaining records of relevant VA medical treatment. 38 U.S.C. §5103A(c)(2); 38 C.F.R. § 3.159(c)(2), (c)(3). Accordingly, the case is REMANDED for the following action: 1. The AOJ should obtain any outstanding medical records from VA treatment facilities identified by the veteran. Follow the procedures for obtaining the records set forth by 38 C.F.R. § 3.159(c). 2. After any additional records are associated with the claims file, the AOJ should schedule the Veteran for a new VA dermatologic examination to assess the current severity of his pseudofolliculitis barbae disability. All necessary diagnostic testing and evaluation should be performed, and all findings set forth in detail. 3. After completing the above development, the AOJ should review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 4. Thereafter, the AOJ should consider all of the evidence of record and readjudicate the claim on appeal. If the benefit sought is not granted, issue a Supplemental Statement of the Case ("SSOC") and allow the Veteran and his representative an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2012). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs